| NPI | 1164703153 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MO 2014008349) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: KS 52-75482-121) |
| Enumeration Date | 2011-09-02 |
| Last Update Date | 2015-10-03 |