| NPI | 1508306671 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WI 7597-33) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WI 195687-30) |
| Enumeration Date | 2017-03-08 |
| Last Update Date | 2017-04-03 |