| NPI | 1235781782 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5011989) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: NC 5011989) |
| Enumeration Date | 2019-07-15 |
| Last Update Date | 2020-10-26 |