| NPI | 1255696597 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3007504) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: KY 1117485) |
| 363LF0000X Nurse Practitioner, Family (Licence: CA 95002557) | |
| 163W00000X Registered Nurse (Licence: CA 95063617) | |
| Enumeration Date | 2012-07-12 |
| Last Update Date | 2016-04-08 |