| NPI | 1871166884 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: TX 1082389) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MA RN2351545) |
| Enumeration Date | 2021-07-19 |
| Last Update Date | 2025-03-03 |