| NPI | 1164961538 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LG0600X Nurse Practitioner Gerontology (Licence: VA 0024174489) |
| Additional Taxonomies | 314000000X Skilled Nursing Facility (Licence: VA 0024174489) |
| 363L00000X Nurse Practitioner (Licence: VA 0024174489) | |
| 363LA2200X Nurse Practitioner Adult Health (Licence: VA 0024174489) | |
| 363LP2300X Nurse Practitioner Primary Care (Licence: VA 0024174489) | |
| Enumeration Date | 2017-02-18 |
| Last Update Date | 2017-02-23 |