| NPI | 1124436555 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: AK 1525) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: TX 800703) |
| Enumeration Date | 2014-07-29 |
| Last Update Date | 2015-04-02 |