| NPI | 1154735900 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: TN 150303) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: TN 18857) |
| Enumeration Date | 2014-06-19 |
| Last Update Date | 2018-05-22 |