| NPI | 1609229681 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5012285) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: SC 20313) |
| Enumeration Date | 2016-07-14 |
| Last Update Date | 2022-02-10 |