| NPI | 1508498015 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WA AP61044253) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: OR 202001367NP-PP) |
| Enumeration Date | 2020-02-12 |
| Last Update Date | 2021-04-09 |