| NPI | 1063831824 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: OR 202001123) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: WI 173722-30) |
| Enumeration Date | 2014-04-09 |
| Last Update Date | 2020-02-04 |