| NPI | 1437143161 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ID NP-823A) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WY 21058.315) |
| Enumeration Date | 2005-09-08 |
| Last Update Date | 2021-03-17 |