| NPI | 1205076130 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 163W00000X Registered Nurse (Licence: OR 200842264RN) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: UT 199782-4405) |
| Enumeration Date | 2009-03-05 |
| Last Update Date | 2011-12-12 |