| NPI | 1083015382 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MO 2015025676) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MO 151527) |
| Enumeration Date | 2014-09-06 |
| Last Update Date | 2015-08-05 |