| NPI | 1790305746 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: GA RN293871) |
| Additional Taxonomies | 363LP2300X Nurse Practitioner, Primary Care (Licence: GA NCO-000001) |
| Enumeration Date | 2020-04-20 |
| Last Update Date | 2023-03-06 |