| NPI | 1124013743 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: VA 0024172458) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: SC 18740) |
| 363LF0000X Nurse Practitioner Family (Licence: GA RN049375 NP) | |
| Enumeration Date | 2005-09-20 |
| Last Update Date | 2021-08-30 |