| NPI | 1194384974 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: VT 101-0134363) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: VT 026.0123321) |
| Enumeration Date | 2019-06-06 |
| Last Update Date | 2021-05-06 |