| NPI | 1619911344 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: GA RN222121) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 363LF0000X Nurse Practitioner, Family (Licence: CO 990345) | |
| Enumeration Date | 2006-06-15 |
| Last Update Date | 2019-10-11 |