| NPI | 1902539976 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ID 54041) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: ID 54041) |
| Enumeration Date | 2022-07-06 |
| Last Update Date | 2024-02-12 |