| NPI | 1780226159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL APRN11004544) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WV 123553) |
| Enumeration Date | 2019-10-17 |
| Last Update Date | 2025-12-11 |