| NPI | 1356815203 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WV APRN75935-NP-C) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: OH APRN.CNP.024059) |
| Enumeration Date | 2019-01-14 |
| Last Update Date | 2021-04-13 |