| NPI | 1104225648 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: MO 2014020747) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: CA 95006304) |
| Enumeration Date | 2014-08-21 |
| Last Update Date | 2021-02-12 |