| NPI | 1255695664 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3007487) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: IN 28194658A) |
| Enumeration Date | 2012-06-29 |
| Last Update Date | 2018-03-12 |