| NPI | 1477606846 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LA2200X Nurse Practitioner Adult Health (Licence: FL 11005766) |
| Additional Taxonomies | 174400000X Specialist (Licence: FL MA36367) |
| 363LF0000X Nurse Practitioner Family (Licence: FL 11005766) | |
| Enumeration Date | 2007-01-19 |
| Last Update Date | 2022-10-04 |