| NPI | 1558882019 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TN 22868) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: VA 0024174973) |
| 363LF0000X Nurse Practitioner Family (Licence: TN 22868) | |
| Enumeration Date | 2017-07-05 |
| Last Update Date | 2021-07-21 |