| NPI | 1306244298 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: SC 23793) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MS 901661) |
| Enumeration Date | 2014-12-09 |
| Last Update Date | 2021-02-24 |