| NPI | 1164805362 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NM 54691) |
| Additional Taxonomies | 163WP2201X Registered Nurse, Ambulatory Care (Licence: NM RN-75449) |
| Enumeration Date | 2015-07-07 |
| Last Update Date | 2021-10-05 |