| NPI | 1578506390 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: OR 200650104NP) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: LA AP04764) |
| 363L00000X Nurse Practitioner (Licence: IA A-103474) | |
| Enumeration Date | 2006-06-13 |
| Last Update Date | 2013-06-07 |