| NPI | 1780476697 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: SD CP003700) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: SD R050507) |
| Enumeration Date | 2025-05-19 |
| Last Update Date | 2025-06-30 |