| NPI | 1629014907 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: GA 147488) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: GA 147488) |
| Enumeration Date | 2006-06-22 |
| Last Update Date | 2007-07-08 |