| NPI | 1134686538 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NE 112739) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NE 75462) |
| Enumeration Date | 2019-02-22 |
| Last Update Date | 2019-03-20 |