| NPI | 1760945729 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KY 3013650) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: KY 1135877) |
| Enumeration Date | 2019-04-08 |
| Last Update Date | 2022-02-04 |