NPI | 1104387992 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: VA 0024176906) |
Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TN 25773) |
Enumeration Date | 2019-03-26 |
Last Update Date | 2021-09-17 |