| NPI | 1407366982 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WV APRN66161) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: KY 3011737) |
| 363LF0000X Nurse Practitioner, Family (Licence: OH 021586) | |
| Enumeration Date | 2017-10-10 |
| Last Update Date | 2023-11-27 |