| NPI | 1114322955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: VA 0024173341) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WV APRN82732-NP-C) |
| Enumeration Date | 2014-10-22 |
| Last Update Date | 2021-04-01 |