| NPI | 1104293463 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MS 885821) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MS R885821) |
| Enumeration Date | 2015-08-21 |
| Last Update Date | 2020-07-24 |