| NPI | 1225365406 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TN 14443) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: VA 0024171677) |
| Enumeration Date | 2009-11-10 |
| Last Update Date | 2019-01-11 |