| NPI | 1295911642 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: LA RN094672) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: LA AP05434) |
| 163W00000X Registered Nurse (Licence: LA RN094672) | |
| Enumeration Date | 2008-01-16 |
| Last Update Date | 2012-07-23 |