| NPI | 1356851893 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3011811) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: OH 021924) |
| Enumeration Date | 2017-10-11 |
| Last Update Date | 2023-05-15 |