| NPI | 1114579596 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: UT 11425353-4405) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: IA A155585) |
| 363LF0000X Nurse Practitioner, Family (Licence: IL 209.019352) | |
| Enumeration Date | 2019-07-15 |
| Last Update Date | 2019-10-30 |