| NPI | 1003122201 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: KY 3006597) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: KY 6597) |
| Enumeration Date | 2010-08-25 |
| Last Update Date | 2014-10-02 |