| NPI | 1417056987 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 275200) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: CA 275299) |
| 363LP2300X Nurse Practitioner, Primary Care (Licence: CA 275200) | |
| Enumeration Date | 2006-09-21 |
| Last Update Date | 2007-07-08 |