| NPI | 1063771392 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: AL 1-061035) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AL 1-061035) |
| Enumeration Date | 2012-05-07 |
| Last Update Date | 2012-05-07 |