| NPI | 1073062295 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ID 62319) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WA AP60693813) |
| Enumeration Date | 2016-09-28 |
| Last Update Date | 2021-12-13 |