| NPI | 1194097105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3007103) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: TN 20070) |
| 363LF0000X Nurse Practitioner, Family (Licence: KY 3007103) | |
| Enumeration Date | 2012-02-07 |
| Last Update Date | 2018-04-17 |