| NPI | 1104168905 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TN 17576) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: VA 0024170760) |
| Enumeration Date | 2013-03-20 |
| Last Update Date | 2017-02-16 |