| NPI | 1811858053 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2015022724) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: MO 2025046992) |
| Enumeration Date | 2025-11-18 |
| Last Update Date | 2026-02-20 |