| NPI | 1003457995 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95012579) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: OH APRN.CNP.0029519) |
| Enumeration Date | 2019-10-02 |
| Last Update Date | 2021-10-28 |