| NPI | 1063739621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: AR A02941) |
| Additional Taxonomies | 363LP2300X Nurse Practitioner, Primary Care (Licence: OH COA 09013-NP) |
| Enumeration Date | 2010-04-22 |
| Last Update Date | 2012-11-05 |