| NPI | 1295179091 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3007980) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IN 01045734A) |
| Enumeration Date | 2013-04-23 |
| Last Update Date | 2015-06-24 |