| NPI | 1477955284 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5007327) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: NC F0814732) |
| Enumeration Date | 2014-09-24 |
| Last Update Date | 2017-10-19 |