| NPI | 1902255599 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ID 54136) |
| Additional Taxonomies | 363LP2300X Nurse Practitioner Primary Care (Licence: UT 9812985-4405) |
| Enumeration Date | 2016-06-06 |
| Last Update Date | 2024-11-25 |