| NPI | 1619271681 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5010394) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: SC 4430) |
| Enumeration Date | 2011-01-05 |
| Last Update Date | 2020-10-26 |