| NPI | 1104082197 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: OR 201703016NP-PP) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: OR 201703016NP-PP) |
| Enumeration Date | 2008-07-30 |
| Last Update Date | 2019-06-18 |