| NPI | 1770255283 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: OR 202111391NP-PP) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: OR pending) |
| Enumeration Date | 2021-10-03 |
| Last Update Date | 2021-10-15 |