| NPI | 1417940347 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL 1763832) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: FL ARNP1763832) |
| Enumeration Date | 2005-08-25 |
| Last Update Date | 2017-01-31 |