| NPI | 1477052496 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 308585) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MS 902485) |
| 363LF0000X Nurse Practitioner, Family (Licence: LA AP09766) | |
| 363LF0000X Nurse Practitioner, Family (Licence: NC 308585) | |
| Enumeration Date | 2018-02-05 |
| Last Update Date | 2022-12-01 |