| NPI | 1417016759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5015447) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: AZ TAP2564) |
| Enumeration Date | 2006-12-06 |
| Last Update Date | 2022-04-07 |