| NPI | 1821620451 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5012830) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MO 2021021010) |
| 363L00000X Nurse Practitioner (Licence: OK 204420) | |
| Enumeration Date | 2020-02-11 |
| Last Update Date | 2024-04-17 |