| 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 |