| NPI | 1629055918 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 150815) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 201017) |
| Enumeration Date | 2005-12-28 |
| Last Update Date | 2019-06-11 |