| NPI | 1124511738 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: VA 0024176276) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: VA 0001258411) |
| Enumeration Date | 2018-06-08 |
| Last Update Date | 2021-07-30 |