| NPI | 1922990845 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WV 124353) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: WV 102122) |
| Enumeration Date | 2025-07-16 |
| Last Update Date | 2025-10-15 |