| NPI | 1376915678 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2015038021) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: MO 2015038021) |
| 363LG0600X Nurse Practitioner, Gerontology (Licence: MO 2015038021) | |
| Enumeration Date | 2015-10-26 |
| Last Update Date | 2015-10-26 |