| NPI | 1356376990 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WV 31894) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: WV 31894) |
| Enumeration Date | 2006-07-12 |
| Last Update Date | 2023-03-07 |