| NPI | 1063926988 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP2300X Nurse Practitioner, Primary Care (Licence: VA 0024175658) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: VA 0024175658) |
| 363L00000X Nurse Practitioner (Licence: WV APRN99520) | |
| 363LA2200X Nurse Practitioner, Adult Health (Licence: VA 0024175658) | |
| Enumeration Date | 2017-11-30 |
| Last Update Date | 2024-05-01 |