| NPI | 1568094969 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MO 2019045211) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: KS 53-79116-121) |
| Enumeration Date | 2020-02-04 |
| Last Update Date | 2020-02-04 |