| NPI | 1295366219 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: LA 211677) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: LA RN127549) |
| Enumeration Date | 2020-01-29 |
| Last Update Date | 2020-01-30 |