| NPI | 1154834596 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: PA SP019894) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: DE LI-0049405) |
| Enumeration Date | 2017-11-08 |
| Last Update Date | 2022-09-12 |