| NPI | 1023534500 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: KY 3012201) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: IN NONE) |
| Enumeration Date | 2017-08-16 |
| Last Update Date | 2022-07-21 |