| NPI | 1760863955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: AZ 255934) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NM R60159) |
| Enumeration Date | 2015-06-12 |
| Last Update Date | 2023-06-22 |