| NPI | 1548770175 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LG0600X Nurse Practitioner, Gerontology (Licence: KY 3011789) |
| Additional Taxonomies | 363LG0600X Nurse Practitioner, Gerontology (Licence: IN 71010192A) |
| Enumeration Date | 2017-10-10 |
| Last Update Date | 2020-07-24 |