| NPI | 1114152758 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WA AP60240764) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: ID N-35393) |
| 363L00000X Nurse Practitioner (Licence: ID NP-917A) | |
| Enumeration Date | 2009-05-27 |
| Last Update Date | 2016-11-08 |