| NPI | 1265075642 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: VA 0024178795) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: VA 0001263149) |
| Enumeration Date | 2019-10-18 |
| Last Update Date | 2020-02-14 |