| NPI | 1912620402 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: VA 0024194227) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: WA RN60793078) |
| Enumeration Date | 2022-09-21 |
| Last Update Date | 2025-09-26 |