| NPI | 1790992378 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL APRN9196918) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: FL PT22471) |
| Enumeration Date | 2007-05-16 |
| Last Update Date | 2025-06-25 |