| NPI | 1366865834 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MO 2014013266) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: KS 53-76215-041) |
| Enumeration Date | 2014-02-03 |
| Last Update Date | 2014-06-10 |