| NPI | 1023550522 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3010546) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: KY 3010546) |
| Enumeration Date | 2016-11-15 |
| Last Update Date | 2018-03-23 |