| NPI | 1043822372 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: WA AP61091392) |
| Additional Taxonomies | 261QM1300X Clinic/Center Multi-Specialty |
| 332B00000X Durable Medical Equipment & Medical Supplies | |
| Enumeration Date | 2020-08-18 |
| Last Update Date | 2020-08-18 |