| NPI | 1023382207 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: MD AC003216)  | 
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: VA 0024169733)  | 
| Enumeration Date | 2012-03-06 | 
| Last Update Date | 2023-02-09 |