| NPI | 1811542665 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11024743) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 321-P.A) |
| Enumeration Date | 2019-08-08 |
| Last Update Date | 2024-02-28 |