| NPI | 1275032963 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: PA SP018554) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA SP018554) |
| Enumeration Date | 2018-02-07 |
| Last Update Date | 2021-06-01 |