| NPI | 1396741799 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: CO 79268) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NE 60259) |
| Enumeration Date | 2005-06-22 |
| Last Update Date | 2016-03-22 |