| NPI | 1942972187 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: WY 48418) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WY 48418) |
| Enumeration Date | 2021-10-05 |
| Last Update Date | 2025-05-23 |