| NPI | 1053384495 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: LA RN073531-AP03121) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: LA RN073531) |
| 363AS0400X Physician Assistant, Surgical (Licence: LA RN073531) | |
| Enumeration Date | 2006-02-08 |
| Last Update Date | 2012-08-08 |