| NPI | 1720695224 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: SD CP002047) | 
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: IA A160877) | 
| 363LF0000X Nurse Practitioner, Family (Licence: NE 113865) | |
| Enumeration Date | 2020-09-29 | 
| Last Update Date | 2025-04-25 |