| NPI | 1396800462 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5005959) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: CA 11637) |
| Enumeration Date | 2006-12-27 |
| Last Update Date | 2013-01-04 |