| NPI | 1972388569 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP2300X Nurse Practitioner, Primary Care (Licence: WI 7653-23) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2023-08-30 |
| Last Update Date | 2024-04-23 |