| NPI | 1609864180 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: PA UP005328B) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MD R130259) |
| Enumeration Date | 2005-10-10 |
| Last Update Date | 2024-05-23 |