| NPI | 1508388240 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL APRN9343369) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: FL ARNP9343369) |
| 363LF0000X Nurse Practitioner Family (Licence: GA RN276305) | |
| Enumeration Date | 2017-07-14 |
| Last Update Date | 2019-08-30 |