| NPI | 1275946964 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MS R890572) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: LA 218275) |
| Enumeration Date | 2014-06-10 |
| Last Update Date | 2021-02-26 |