| NPI | 1083634620 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WA AP30007491) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: UT 309994-4405) |
| Enumeration Date | 2006-07-19 |
| Last Update Date | 2021-03-01 |