| NPI | 1164412193 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TN 22788) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: AZ AP1416) |
| Enumeration Date | 2005-10-21 |
| Last Update Date | 2021-11-04 |