| NPI | 1548253594 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NM CNP00646) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NM R31435) |
| Enumeration Date | 2005-08-25 |
| Last Update Date | 2023-02-16 |