| NPI | 1508855255 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: TN APN0000013655) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: NC 104366) |
| Enumeration Date | 2005-10-17 |
| Last Update Date | 2009-02-19 |