| NPI | 1487140562 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TN 26258) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: VA 0024176341) |
| Enumeration Date | 2018-07-02 |
| Last Update Date | 2019-09-03 |