| NPI | 1932693504 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3012416) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: TN 31293) |
| Enumeration Date | 2018-06-18 |
| Last Update Date | 2023-03-01 |