| NPI | 1902478688 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WA AP61625969) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: VA 0024182100) |
| Enumeration Date | 2021-07-13 |
| Last Update Date | 2025-02-04 |