| NPI | 1568875102 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: SD CP000858) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: SD CP000858) |
| Enumeration Date | 2014-06-10 |
| Last Update Date | 2017-07-14 |