| NPI | 1124542295 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: GA RN271430) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: TX 732608) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-08-01 |
| Last Update Date | 2018-03-17 |