| NPI | 1134123995 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IN 71000351A) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KY 3545P) |
| Enumeration Date | 2005-06-09 |
| Last Update Date | 2014-05-08 |