| NPI | 1447762984 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KS 78052) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MO 2017021477) |
| Enumeration Date | 2017-10-24 |
| Last Update Date | 2021-07-08 |