| NPI | 1063415644 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: WA AP30006881) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: OR 200450156NP) |
| Enumeration Date | 2005-05-27 |
| Last Update Date | 2018-09-25 |