| NPI | 1164778924 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: OH COA.13574-NP) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: OH COA.13574-NP) |
| 363LF0000X Nurse Practitioner, Family (Licence: KY 3007647) | |
| Enumeration Date | 2012-07-31 |
| Last Update Date | 2016-12-16 |