| NPI | 1922673573 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 12598) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NY F347644-01) |
| Enumeration Date | 2021-05-25 |
| Last Update Date | 2025-05-06 |