| NPI | 1235155201 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WV 35607) |
| Additional Taxonomies | 367H00000X Anesthesiologist Assistant (Licence: WV 39835) |
| Enumeration Date | 2006-07-14 |
| Last Update Date | 2007-11-29 |