| NPI | 1134673247 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: PA SP016675) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: PA RN56389) |
| Enumeration Date | 2016-08-05 |
| Last Update Date | 2016-12-28 |