| NPI | 1629052055 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: AK 788) |
| Additional Taxonomies | 163WG0000X Registered Nurse General Practice (Licence: AK 21813) |
| Enumeration Date | 2005-11-30 |
| Last Update Date | 2012-04-03 |