| NPI | 1104112788 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NC 5005238) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NC 5005238) |
| Enumeration Date | 2011-06-22 |
| Last Update Date | 2022-04-06 |