| NPI | 1104415140 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IA A159727) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: IA A159727) |
| Enumeration Date | 2021-01-14 |
| Last Update Date | 2021-06-03 |