| NPI | 1205302460 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2018035987) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MO 2018035987) |
| Enumeration Date | 2018-10-15 |
| Last Update Date | 2022-09-16 |