| NPI | 1477978302 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: PA SP016602) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WV APRN78604NP) |
| Enumeration Date | 2014-03-01 |
| Last Update Date | 2016-09-28 |