| NPI | 1164569703 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TN 16762) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NY 355160) |
| 111N00000X Chiropractor (Licence: AL 2025) | |
| Enumeration Date | 2007-01-31 |
| Last Update Date | 2024-09-26 |