| NPI | 1104233816 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: VT 101.0102067) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: VT 101.0102067) |
| Enumeration Date | 2014-07-14 |
| Last Update Date | 2014-11-26 |