| NPI | 1063576619 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ID NP-1688A) |
| Additional Taxonomies | 111N00000X Chiropractor (Licence: ID CHIA1053) |
| Enumeration Date | 2006-12-20 |
| Last Update Date | 2016-01-27 |