| NPI | 1629547039 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: PA SP019596) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: PA RN622044) |
| Enumeration Date | 2018-11-14 |
| Last Update Date | 2018-11-14 |