| NPI | 1124124904 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: ME R053512) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NH 0434312303) |
| Enumeration Date | 2006-09-16 |
| Last Update Date | 2007-07-08 |