| NPI | 1578130662 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: WI 11591) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WI 221516) |
| Enumeration Date | 2021-06-07 |
| Last Update Date | 2021-12-15 |