| NPI | 1053706556 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LA2200X Nurse Practitioner Adult Health (Licence: MO AG1214019) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: MO AG1214019) |
| Enumeration Date | 2015-04-01 |
| Last Update Date | 2018-05-14 |