| NPI | 1114951647 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ID NP-833A) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WA AP60970561) |
| 363LF0000X Nurse Practitioner, Family (Licence: ID NP833A) | |
| 163W00000X Registered Nurse (Licence: NE 52962) | |
| 363LF0000X Nurse Practitioner, Family (Licence: MD 0351131) | |
| 363LF0000X Nurse Practitioner, Family (Licence: NE 110472) | |
| Enumeration Date | 2006-07-10 |
| Last Update Date | 2021-01-28 |