NPI | 1952028037 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL 11041706) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 001478) |
Enumeration Date | 2022-10-20 |
Last Update Date | 2025-08-15 |