| NPI | 1245725639 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2018020749) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KS 78255) |
| Enumeration Date | 2018-06-27 |
| Last Update Date | 2018-06-27 |