| NPI | 1588945489 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: SC 23152) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WV 67249) |
| Enumeration Date | 2011-09-06 |
| Last Update Date | 2022-11-02 |