| NPI | 1104209568 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NE 111840) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: NE 111840) |
| Enumeration Date | 2015-07-02 |
| Last Update Date | 2019-10-17 |