| NPI | 1306807102 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NH 054054-21) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MA 250357) |
| Enumeration Date | 2006-03-31 |
| Last Update Date | 2015-03-16 |