| NPI | 1144881665 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2019035092) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: AR 121399) |
| Enumeration Date | 2019-06-25 |
| Last Update Date | 2019-10-30 |