| NPI | 1285143875 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: WV 104052) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KY 3011515) |
| Enumeration Date | 2017-09-26 |
| Last Update Date | 2021-11-23 |