| NPI | 1063964302 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: AZ AP9622) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: AZ AP9622) |
| Enumeration Date | 2016-11-03 |
| Last Update Date | 2021-06-01 |