| NPI | 1275778987 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KY 3005686) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: KY 5686P) |
| Enumeration Date | 2008-12-09 |
| Last Update Date | 2014-07-08 |