| NPI | 1962010785 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TN 27376) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: GA RN00000) |
| Enumeration Date | 2020-07-17 |
| Last Update Date | 2022-04-20 |