| NPI | 1083042618 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11002944) | 
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: FL rn9325936) | 
| 207Q00000X Family Medicine (Licence: FL APRN11002944) | |
| Enumeration Date | 2013-10-16 | 
| Last Update Date | 2019-07-30 |