| NPI | 1609368075 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KS 5878231072) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: KS 58-78231-072) |
| Enumeration Date | 2018-06-01 |
| Last Update Date | 2018-06-01 |