| NPI | 1336571447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NM CNP-02396) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MO 2013017928) |
| Enumeration Date | 2013-07-31 |
| Last Update Date | 2016-07-25 |