| NPI | 1104234871 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP2300X Nurse Practitioner Primary Care (Licence: VA 0024172585) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: DC RN1034284) |
| Enumeration Date | 2014-07-25 |
| Last Update Date | 2018-05-17 |