| NPI | 1053841866 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: GA RN22740) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: GA RN22740) |
| Enumeration Date | 2017-06-14 |
| Last Update Date | 2020-05-05 |