| NPI | 1912577008 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NC 5016250) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11015076) |
| Enumeration Date | 2021-06-30 |
| Last Update Date | 2022-05-24 |