| NPI | 1396207361 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: AL 1-161504) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: LA RN149926) |
| Enumeration Date | 2019-04-01 |
| Last Update Date | 2021-01-15 |