| NPI | 1235512666 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP2300X Nurse Practitioner, Primary Care (Licence: LA AP08387) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: LA RN123903) |
| 363LF0000X Nurse Practitioner, Family (Licence: LA AP08387) | |
| Enumeration Date | 2015-07-02 |
| Last Update Date | 2018-09-06 |