| NPI | 1245682038 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5012587) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: SC 20311) |
| Enumeration Date | 2016-07-06 |
| Last Update Date | 2021-03-31 |