| NPI | 1184016529 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KS 53-76641-082) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MO 2015001951) |
| Enumeration Date | 2015-02-23 |
| Last Update Date | 2022-01-04 |