| NPI | 1083026892 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: GA 203897) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: GA RN203897) |
| Enumeration Date | 2014-05-28 |
| Last Update Date | 2016-02-10 |