| NPI | 1902568942 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: SC 27568) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WI 1135733) |
| Enumeration Date | 2021-10-07 |
| Last Update Date | 2023-09-14 |