| NPI | 1629296603 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KY 3015925) |
| Additional Taxonomies | 111NR0400X (Licence: KY 4973) |
| Enumeration Date | 2007-04-23 |
| Last Update Date | 2021-07-07 |