| NPI | 1376856211 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3006527) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: KY 6527P) |
| 363LA2200X Nurse Practitioner, Adult Health (Licence: OH 328712) | |
| Enumeration Date | 2010-07-21 |
| Last Update Date | 2020-04-10 |