| NPI | 1407929235 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: OR 200950143NP) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: OR 200342130RN) |
| 163W00000X Registered Nurse (Licence: NM RN-70260) | |
| 363L00000X Nurse Practitioner (Licence: NM TL-00256) | |
| Enumeration Date | 2006-11-17 |
| Last Update Date | 2012-07-12 |