| NPI | 1245666320 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NM 55571) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: SC 18491) |
| Enumeration Date | 2013-09-19 |
| Last Update Date | 2019-10-31 |