| NPI | 1174879282 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IA L166512) |
| Additional Taxonomies | 363LA2100X Nurse Practitioner, Acute Care (Licence: MO 2012024476) |
| Enumeration Date | 2012-07-25 |
| Last Update Date | 2022-02-18 |