| NPI | 1205367935 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: PA SP020999) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WV 96188) |
| Enumeration Date | 2017-03-24 |
| Last Update Date | 2020-10-06 |