| NPI | 1508843541 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: LA RN 84969) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: LA APRN03736) |
| Enumeration Date | 2005-12-30 |
| Last Update Date | 2007-07-08 |