| NPI | 1215950365 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ID NP-1290A) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: OR 200350127NP-FNP-PP) |
| Enumeration Date | 2006-07-26 |
| Last Update Date | 2022-07-19 |