| NPI | 1508319021 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: PA SP016289) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: PA RN616382) |
| Enumeration Date | 2016-08-02 |
| Last Update Date | 2021-01-16 |