| NPI | 1063585966 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: AR A003106) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MO 128445) |
| Enumeration Date | 2006-11-16 |
| Last Update Date | 2013-02-22 |