| NPI | 1184614901 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KY 3003280) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KY 3003280) |
| Enumeration Date | 2005-10-24 |
| Last Update Date | 2020-06-22 |