| NPI | 1255746202 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TN 20722) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: VA 0024171838) |
| Enumeration Date | 2014-06-29 |
| Last Update Date | 2018-07-10 |