| NPI | 1629627872 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: NC 5012614) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MA RN2320616) |
| Enumeration Date | 2019-09-10 |
| Last Update Date | 2021-09-29 |