| NPI | 1578654224 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: UT 197032-4405) |
| Additional Taxonomies | 225400000X Rehabilitation Practitioner (Licence: UT 197032-4405) |
| Enumeration Date | 2006-09-27 |
| Last Update Date | 2017-09-12 |