| NPI | 1265430458 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: GA RN134018) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: GA 791420) |
| Enumeration Date | 2005-07-12 |
| Last Update Date | 2012-11-29 |