| NPI | 1992496426 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: VA 0024194232) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: AL 1-164363) |
| Enumeration Date | 2023-05-16 |
| Last Update Date | 2025-10-10 |