| NPI | 1780192500 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5010176) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IN 71016798A) |
| Enumeration Date | 2018-01-15 |
| Last Update Date | 2025-09-15 |