| NPI | 1962093781 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP2300X Nurse Practitioner Primary Care (Licence: AZ 253415) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: AZ 253415) |
| Enumeration Date | 2021-02-03 |
| Last Update Date | 2021-03-16 |