| NPI | 1629529391 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KY 3010743) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: KY 1136319) |
| Enumeration Date | 2016-10-18 |
| Last Update Date | 2019-09-09 |