| NPI | 1043691363 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2015018040) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KS 53-76841) |
| 363LF0000X Nurse Practitioner Family (Licence: KS 53-76841) | |
| 363LF0000X Nurse Practitioner Family (Licence: MO 2015018040) | |
| Enumeration Date | 2015-06-11 |
| Last Update Date | 2022-05-18 |