| NPI | 1508010547 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: LA AP03189) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: LA RN071430) |
| Enumeration Date | 2008-11-04 |
| Last Update Date | 2015-08-28 |