| NPI | 1346780616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KS 77492) |
| Additional Taxonomies | 363LP2300X Nurse Practitioner, Primary Care (Licence: KS 53-77492-062) |
| 363LF0000X Nurse Practitioner, Family (Licence: KS 53-77492-062) | |
| Enumeration Date | 2017-03-06 |
| Last Update Date | 2021-06-07 |