| NPI | 1790662294 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WI 17302) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WI 17302-33) |
| Enumeration Date | 2025-08-18 |
| Last Update Date | 2025-10-14 |