| NPI | 1366072845 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: UT 12929059-4405) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: OH RN.361965) |
| 171000000X Military Health Care Provider | |
| 363LF0000X Nurse Practitioner, Family (Licence: UT 12929059-4405) | |
| 363LW0102X Nurse Practitioner, Women's Health (Licence: UT 12929059-4405) | |
| Enumeration Date | 2020-01-23 |
| Last Update Date | 2022-07-13 |