| NPI | 1174936769 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NE 111696) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NE 70861) |
| Enumeration Date | 2014-06-11 |
| Last Update Date | 2014-11-24 |