| NPI | 1124396403 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MS 902029) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: LA AP06578) |
| Enumeration Date | 2011-12-01 |
| Last Update Date | 2018-03-17 |