| NPI | 1316942790 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IA A116795) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MS R878488) |
| Enumeration Date | 2005-06-14 |
| Last Update Date | 2013-06-19 |