| NPI | 1033665963 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: SD CP001123) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: IA A149652) |
| 363LF0000X Nurse Practitioner, Family (Licence: MN 6253) | |
| Enumeration Date | 2016-08-31 |
| Last Update Date | 2019-07-08 |