| NPI | 1639408198 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL 11008179) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: FL RN9238447) |
| Enumeration Date | 2009-12-12 |
| Last Update Date | 2020-08-31 |