| NPI | 1164940466 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NE 112346) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NE 73722) |
| Enumeration Date | 2017-09-07 |
| Last Update Date | 2017-10-17 |