| NPI | 1639372873 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: CT 4678) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: CT E52990) |
| Enumeration Date | 2007-06-06 |
| Last Update Date | 2012-10-15 |