| NPI | 1194820555 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ID RN33608) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: ID NP675A) |
| Enumeration Date | 2006-09-13 |
| Last Update Date | 2019-08-28 |