| NPI | 1336596600 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3010296) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MN 10367) |
| 363LF0000X Nurse Practitioner Family (Licence: CO APN.0997279-NP) | |
| Enumeration Date | 2016-05-17 |
| Last Update Date | 2023-12-20 |