| NPI | 1578561262 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MS 810467) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: TN 16792) |
| 363LF0000X Nurse Practitioner, Family (Licence: TN APN0000016792) | |
| Enumeration Date | 2005-07-07 |
| Last Update Date | 2023-06-27 |