| NPI | 1376812818 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KS 53-75487-021) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MO 2011039961) |
| Enumeration Date | 2011-12-28 |
| Last Update Date | 2022-07-21 |