| NPI | 1073811717 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: MS R879013) |
| Additional Taxonomies | 225X00000X Occupational Therapist (Licence: MS OT1385) |
| 363LF0000X Nurse Practitioner Family (Licence: NM CNP-02475) | |
| 363LF0000X Nurse Practitioner Family (Licence: AZ AP5005) | |
| Enumeration Date | 2011-03-04 |
| Last Update Date | 2021-03-02 |