| NPI | 1124165485 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KS 74162) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: KS 13582171111) |
| Enumeration Date | 2007-01-30 |
| Last Update Date | 2012-09-27 |