| NPI | 1114994746 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: LA AP04196) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: LA RN089438) |
| Enumeration Date | 2006-03-02 |
| Last Update Date | 2014-04-16 |