| NPI | 1164829123 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QU0200X Clinic/Center, Urgent Care (Licence: WA AP60521209) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WA AP60521209) |
| Enumeration Date | 2014-11-19 |
| Last Update Date | 2022-04-29 |