| NPI | 1285921312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: WV 68999) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: KY 3006910) |
| Enumeration Date | 2011-07-10 |
| Last Update Date | 2021-04-22 |