| NPI | 1346764347 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: PA SP017678) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: PA RN626435) |
| Enumeration Date | 2017-08-01 |
| Last Update Date | 2020-08-19 |