| NPI | 1912543422 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: OR 10050481) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NC 5017276) |
| 363L00000X Nurse Practitioner (Licence: NC 5017276) | |
| Enumeration Date | 2019-11-19 |
| Last Update Date | 2026-04-30 |