| NPI | 1215437603 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5010285) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NC 5010285) |
| Enumeration Date | 2018-02-13 |
| Last Update Date | 2018-10-22 |