| NPI | 1962389866 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MS 907747) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MS 921317) |
| Enumeration Date | 2025-08-20 |
| Last Update Date | 2025-09-26 |