| NPI | 1104441914 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: KY 3015684) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: KY 1086308) |
| Enumeration Date | 2020-06-08 |
| Last Update Date | 2021-01-12 |