| NPI | 1972119014 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: MO 2023007556) |
| Additional Taxonomies | 363LG0600X Nurse Practitioner, Gerontology (Licence: MO 2023007556) |
| Enumeration Date | 2020-09-22 |
| Last Update Date | 2024-03-15 |