| NPI | 1215553219 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: WV 107144) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: WV 90381) |
| Enumeration Date | 2020-06-25 |
| Last Update Date | 2021-07-12 |