| NPI | 1366756462 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: MA RN2265382) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: AZ AP3900) |
| 363LF0000X Nurse Practitioner Family (Licence: ME CNP121102) | |
| Enumeration Date | 2010-07-30 |
| Last Update Date | 2013-05-01 |