| NPI | 1497026066 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5013966) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: CT 4881) |
| Enumeration Date | 2012-01-13 |
| Last Update Date | 2021-03-04 |