| NPI | 1801373055 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: VT 101.0132512) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2018-07-20 |
| Last Update Date | 2024-01-04 |