| NPI | 1912508631 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: FL APRN11021580) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: SC 252887) |
| 363AM0700X Physician Assistant Medical (Licence: PR 698-P.A.) | |
| Enumeration Date | 2020-11-09 |
| Last Update Date | 2022-10-31 |