| NPI | 1982379871 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: LA 240350) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MS 904194) |
| Enumeration Date | 2021-08-12 |
| Last Update Date | 2026-03-18 |