| NPI | 1912684655 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5018459) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NC 311536) |
| Enumeration Date | 2023-07-04 |
| Last Update Date | 2023-09-05 |