| NPI | 1053561241 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: OR 200950046NP) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MT 36391) |
| Enumeration Date | 2008-09-24 |
| Last Update Date | 2018-10-08 |