| NPI | 1538731419 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: NE 113660) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: NE 113660) |
| Enumeration Date | 2021-07-12 |
| Last Update Date | 2021-07-19 |