| NPI | 1609121110 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: GA RN197261-NP) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NC 265595) |
| Enumeration Date | 2012-07-20 |
| Last Update Date | 2014-02-09 |