| NPI | 1306125570 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: VA 0024177807) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KY 3007076) |
| Enumeration Date | 2011-08-05 |
| Last Update Date | 2020-10-20 |