| NPI | 1194306795 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KS 53-79589-031) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MO 2020022860) |
| 363LF0000X Nurse Practitioner, Family (Licence: KS 53-79589-031) | |
| 363LF0000X Nurse Practitioner, Family (Licence: MO 2020022860) | |
| Enumeration Date | 2021-04-16 |
| Last Update Date | 2022-01-31 |