| NPI | 1417503483 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 267771) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: NM 57176) |
| Enumeration Date | 2019-08-14 |
| Last Update Date | 2021-09-08 |