| NPI | 1265875546 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: WV 97970) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: PA SP012852) |
| 363L00000X Nurse Practitioner (Licence: PA SP012852) | |
| Enumeration Date | 2013-04-17 |
| Last Update Date | 2022-04-08 |