| NPI | 1821248550 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LG0600X Nurse Practitioner, Gerontology (Licence: CT 180292) |
| Additional Taxonomies | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Enumeration Date | 2008-09-30 |
| Last Update Date | 2025-03-31 |