| NPI | 1174971543 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: AL 1-109947) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: AL 1-109947) |
| Enumeration Date | 2016-05-26 |
| Last Update Date | 2018-10-30 |