| NPI | 1124297031 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TN 16125) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 882-039) |
| Enumeration Date | 2008-02-25 |
| Last Update Date | 2021-05-17 |