| NPI | 1336474659 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 132761) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MO F0809441) |
| Enumeration Date | 2009-10-05 |
| Last Update Date | 2021-04-07 |