| NPI | 1629099122 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: NC 252839) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: FL 2679622) |
| Enumeration Date | 2006-07-21 |
| Last Update Date | 2017-04-17 |