| NPI | 1265805147 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL RN9292639) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: FL 9292639) |
| Enumeration Date | 2015-11-02 |
| Last Update Date | 2020-07-20 |