| NPI | 1821676701 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KY 3016734) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: IN 28236137A) |
| Enumeration Date | 2021-03-31 |
| Last Update Date | 2021-09-29 |