| NPI | 1417298779 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 267800) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TN 17433) |
| 363LP0200X Nurse Practitioner, Pediatrics (Licence: NC 267800) | |
| Enumeration Date | 2013-03-12 |
| Last Update Date | 2018-01-23 |