| NPI | 1497020101 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: WV 63391) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: VA 0024169893) |
| Enumeration Date | 2012-03-13 |
| Last Update Date | 2021-04-22 |