| NPI | 1154366961 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: AR A004183) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AR AT 203) |
| Enumeration Date | 2006-06-17 |
| Last Update Date | 2014-09-25 |