| NPI | 1386719375 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3006886) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: TN 14346) |
| 363LA2200X Nurse Practitioner Adult Health (Licence: TN 14346) | |
| 363LF0000X Nurse Practitioner Family (Licence: KY 3006886) | |
| 363LG0600X Nurse Practitioner Gerontology (Licence: TN 14346) | |
| Enumeration Date | 2006-11-22 |
| Last Update Date | 2014-10-13 |