| NPI | 1104380328 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LA2200X Nurse Practitioner Adult Health (Licence: OH RN280539) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: OH RN.280539) |
| Enumeration Date | 2019-01-23 |
| Last Update Date | 2021-02-26 |