| NPI | 1083139935 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TN 23136) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: VA 0024175255) |
| Enumeration Date | 2017-08-11 |
| Last Update Date | 2017-11-27 |