| NPI | 1467763813 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WI 10069) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: WI 172644-030) |
| Enumeration Date | 2010-06-30 |
| Last Update Date | 2020-07-01 |