| NPI | 1134690910 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP2300X Nurse Practitioner, Primary Care (Licence: TN 25187) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TN 25187) |
| Enumeration Date | 2018-12-05 |
| Last Update Date | 2020-11-13 |