| NPI | 1235190596 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NM CNP-01916) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: PA SP007906) |
| 261QU0200X Clinic/Center, Urgent Care (Licence: PA SP007906) | |
| Enumeration Date | 2006-03-28 |
| Last Update Date | 2014-01-28 |