| NPI | 1740855873 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2021029448) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: KS 13135131121) |
| 163W00000X Registered Nurse (Licence: MO 2017025595) | |
| Enumeration Date | 2021-05-21 |
| Last Update Date | 2022-02-16 |