| NPI | 1811500754 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: VA 0024180435) |
| Additional Taxonomies | 2086S0102X Surgery Surgical Critical Care (Licence: DC 2020039837) |
| Enumeration Date | 2020-08-29 |
| Last Update Date | 2021-03-19 |