| NPI | 1508307190 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2017004715) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IA A155084) |
| Enumeration Date | 2017-03-15 |
| Last Update Date | 2021-01-13 |