| NPI | 1346899846 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IA A166919) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SD CP001633) |
| Enumeration Date | 2019-09-06 |
| Last Update Date | 2022-04-28 |