| NPI | 1194947598 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 163W00000X Registered Nurse (Licence: KY 1085786) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KY 4436P) |
| Enumeration Date | 2007-05-03 |
| Last Update Date | 2007-07-08 |