| NPI | 1245707306 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5011241) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NC 138261) |
| Enumeration Date | 2018-10-26 |
| Last Update Date | 2020-10-26 |