| NPI | 1407123508 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: OH APRN.CNP.023674) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: OR 201142927RN) |
| Enumeration Date | 2011-11-18 |
| Last Update Date | 2018-11-07 |