| NPI | 1508361510 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MD R233931) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: VA 0024176701) |
| Enumeration Date | 2018-03-30 |
| Last Update Date | 2018-12-07 |