| NPI | 1093350803 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL APRN11001625) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: FL 11001625) |
| Enumeration Date | 2019-11-15 |
| Last Update Date | 2019-12-13 |