| NPI | 1528553260 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3014635) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: AL 1-138309) |
| Enumeration Date | 2018-06-26 |
| Last Update Date | 2021-02-05 |