| NPI | 1851937221 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5018639) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: SC 243317) |
| 363LF0000X Nurse Practitioner Family (Licence: NC 5018639) | |
| Enumeration Date | 2019-11-20 |
| Last Update Date | 2025-03-03 |