| NPI | 1104467950 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL 11018408) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: HI 2659) |
| Enumeration Date | 2019-10-03 |
| Last Update Date | 2022-05-02 |