| NPI | 1861969883 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL APRN11000018) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11000018) |
| Enumeration Date | 2018-10-29 |
| Last Update Date | 2021-12-07 |