| NPI | 1598016099 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: SC 20163) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WV 76664) |
| Enumeration Date | 2012-09-24 |
| Last Update Date | 2021-06-10 |