| NPI | 1295139863 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: OR 201407414NP-PP) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: UT 6656184-4405) |
| Enumeration Date | 2014-10-10 |
| Last Update Date | 2014-11-25 |