| NPI | 1053722942 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WA AP60591631) |
| Additional Taxonomies | 363LP2300X Nurse Practitioner, Primary Care (Licence: WA AP60591631) |
| 363LF0000X Nurse Practitioner, Family (Licence: WA AP60591631) | |
| Enumeration Date | 2014-05-13 |
| Last Update Date | 2015-12-29 |