| NPI | 1801561279 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TN 30051) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NC 5016100) |
| Enumeration Date | 2021-08-09 |
| Last Update Date | 2022-08-01 |