| NPI | 1225436876 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: OK OK74696) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: OR 10026228) |
| Enumeration Date | 2014-12-15 |
| Last Update Date | 2024-12-30 |