| NPI | 1053695767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: WV 111221) |
| Additional Taxonomies | 367500000X Nurse Anesthetist, Certified Registered (Licence: WV APRN68169-CRNA) |
| Enumeration Date | 2011-09-30 |
| Last Update Date | 2022-02-23 |