| NPI | 1053705871 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IA A155082) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NY F343808-1) |
| 363L00000X Nurse Practitioner (Licence: VA 0024176683) | |
| 363L00000X Nurse Practitioner (Licence: CO C-APN.0000471) | |
| 363L00000X Nurse Practitioner (Licence: NM CNP-02625) | |
| Enumeration Date | 2015-03-19 |
| Last Update Date | 2019-07-19 |