| NPI | 1790511202 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2024036781) |
| Additional Taxonomies | 363LA2100X Nurse Practitioner, Acute Care (Licence: MO 2024036781) |
| Enumeration Date | 2024-09-11 |
| Last Update Date | 2025-05-09 |