| NPI | 1912782079 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11028547) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL RN9533649) |
| Enumeration Date | 2023-08-28 |
| Last Update Date | 2026-06-27 |