| NPI | 1962234955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11038720) |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: FL 24-391) |
| Enumeration Date | 2024-08-17 |
| Last Update Date | 2025-04-28 |