| NPI | 1063905677 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NC 5011001) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NC 233902) |
| Enumeration Date | 2018-06-08 |
| Last Update Date | 2018-10-15 |