| NPI | 1619955861 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: NC 201112) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: PA SP009515) |
| Enumeration Date | 2006-01-06 |
| Last Update Date | 2016-07-29 |