| NPI | 1053576504 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: UT 2114514405) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: UT 211451-4405) |
| Enumeration Date | 2008-07-24 |
| Last Update Date | 2022-10-13 |