| NPI | 1366519076 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: NC 5005242) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: NC 25013) |
| Enumeration Date | 2006-11-29 |
| Last Update Date | 2013-05-14 |