| NPI | 1306929674 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 900364) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: NC 111952) |
| Enumeration Date | 2006-10-23 |
| Last Update Date | 2020-04-08 |