| NPI | 1154567162 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5004231) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 5004231) |
| Enumeration Date | 2008-12-22 |
| Last Update Date | 2008-12-22 |