| NPI | 1043512734 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5008480) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: NY 305562) |
| Enumeration Date | 2010-12-01 |
| Last Update Date | 2022-05-26 |