| NPI | 1104148626 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: TN APN14812) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: TN RN158503) |
| Enumeration Date | 2010-02-25 |
| Last Update Date | 2020-09-28 |