| NPI | 1023654548 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WA AP61017581) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: ID 67924) |
| Enumeration Date | 2019-11-19 |
| Last Update Date | 2021-12-28 |