| NPI | 1154854255 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: LA AP09641) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: LA RN136771) |
| Enumeration Date | 2017-04-05 |
| Last Update Date | 2018-01-09 |