| NPI | 1912619883 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: SC 26903) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: SC 205520) |
| Enumeration Date | 2022-12-21 |
| Last Update Date | 2023-02-13 |