| NPI | 1770112138 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ID 68018) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: UT 9132375-4405) |
| Enumeration Date | 2020-04-07 |
| Last Update Date | 2025-03-06 |