| NPI | 1194360578 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KY 3014042) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KY 3014042) |
| Enumeration Date | 2019-11-09 |
| Last Update Date | 2020-02-10 |