| NPI | 1124671961 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: CT 8305) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: CT 162343) |
| Enumeration Date | 2019-07-22 |
| Last Update Date | 2019-07-22 |