| NPI | 1154753457 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LG0600X Nurse Practitioner, Gerontology (Licence: OR 201504149NP-PP) |
| Additional Taxonomies | 363LP2300X Nurse Practitioner, Primary Care (Licence: MA RN2275111) |
| 363LP2300X Nurse Practitioner, Primary Care (Licence: OR 201504149NP-PP) | |
| Enumeration Date | 2013-08-08 |
| Last Update Date | 2016-01-05 |