| NPI | 1558763300 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: SC 19047) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: SC 209379) |
| Enumeration Date | 2014-09-24 |
| Last Update Date | 2021-01-25 |