| NPI | 1578974010 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95009002) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KS 53-76450) |
| Enumeration Date | 2014-05-19 |
| Last Update Date | 2018-07-18 |