| NPI | 1134553456 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WI 5402) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: WI 167960) |
| Enumeration Date | 2013-08-22 |
| Last Update Date | 2018-08-29 |