| NPI | 1366570020 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NE 110626) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: IA A097758) |
| Enumeration Date | 2007-03-02 |
| Last Update Date | 2019-06-14 |