| NPI | 1225420490 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: SC 23604) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: TN 19538) |
| 363LP2300X Nurse Practitioner, Primary Care (Licence: TN 19538) | |
| Enumeration Date | 2015-02-25 |
| Last Update Date | 2022-10-31 |