| NPI | 1548570039 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: VA 0024170558) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: OH COA.11893) |
| 363LA2200X Nurse Practitioner, Adult Health (Licence: VA 0024170558) | |
| Enumeration Date | 2010-10-18 |
| Last Update Date | 2022-02-03 |