| NPI | 1124173976 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP2300X Nurse Practitioner, Primary Care (Licence: VA 010142043) |
| Additional Taxonomies | 208D00000X General Practice (Licence: VA 0101042043) |
| Enumeration Date | 2007-01-24 |
| Last Update Date | 2021-07-19 |