| NPI | 1124575972 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NC 5010528) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: SC 20387) |
| Enumeration Date | 2016-09-08 |
| Last Update Date | 2018-05-16 |