| NPI | 1891122321 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: TN 18005) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: VA 0024171609) |
| Enumeration Date | 2013-09-30 |
| Last Update Date | 2023-05-23 |