| NPI | 1558969469 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP2300X Nurse Practitioner Primary Care (Licence: KY 2020044609) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner Adult Health (Licence: KY 1137306) |
| 363LG0600X Nurse Practitioner Gerontology (Licence: KY 1137306) | |
| Enumeration Date | 2020-10-13 |
| Last Update Date | 2020-12-09 |