| NPI | 1922563360 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: WV 121343) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: GA RN282618) |
| Enumeration Date | 2019-02-08 |
| Last Update Date | 2025-10-08 |