| NPI | 1174986699 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TN 20048) |
| Additional Taxonomies | 133V00000X Dietitian, Registered (Licence: TN 2018) |
| Enumeration Date | 2016-04-01 |
| Last Update Date | 2017-01-16 |