| NPI | 1255687620 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KY 3009129) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TN 16799) |
| Enumeration Date | 2012-08-03 |
| Last Update Date | 2022-03-15 |