| NPI | 1336572205 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MT 100650) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MT 32204) |
| Enumeration Date | 2013-08-15 |
| Last Update Date | 2021-07-06 |