| NPI | 1053864819 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TN 21478) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KY 3013649) |
| Enumeration Date | 2016-07-28 |
| Last Update Date | 2021-03-18 |