| NPI | 1003179821 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: OH COA.13402-NP) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: OH COA.13402) |
| Enumeration Date | 2012-06-18 |
| Last Update Date | 2014-02-20 |