| NPI | 1366774705 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5013836) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: VA 0024168640) |
| Enumeration Date | 2010-02-10 |
| Last Update Date | 2021-02-11 |