| NPI | 1942722376 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11022778) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: FL RN9463152) |
| Enumeration Date | 2017-07-07 |
| Last Update Date | 2024-08-02 |