| NPI | 1164815817 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TN 20688) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WV 86493) |
| 363LF0000X Nurse Practitioner, Family (Licence: VA 0024173851) | |
| Enumeration Date | 2015-03-05 |
| Last Update Date | 2023-09-22 |