| NPI | 1912309949 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL 11046343) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: FL RN 9234366) |
| Enumeration Date | 2014-09-22 |
| Last Update Date | 2026-04-09 |