| NPI | 1285101097 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ID 59973) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WA AP61046922) |
| 363LF0000X Nurse Practitioner, Family (Licence: WA AP61046922) | |
| Enumeration Date | 2018-10-30 |
| Last Update Date | 2022-10-03 |