| NPI | 1619360773 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: TN 31164) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: KY 3009277) |
| Enumeration Date | 2015-03-13 |
| Last Update Date | 2022-05-05 |