| NPI | 1417517996 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KS 80189) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NE 112763) |
| Enumeration Date | 2019-06-18 |
| Last Update Date | 2023-02-14 |