| NPI | 1932742582 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KS 79002) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MO 2024032097) |
| Enumeration Date | 2019-10-25 |
| Last Update Date | 2024-09-25 |