| NPI | 1164825923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: AL 1-123152) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NC 271591) |
| 363LF0000X Nurse Practitioner, Family (Licence: NC 5007244) | |
| Enumeration Date | 2014-10-07 |
| Last Update Date | 2023-11-22 |