| NPI | 1639607757 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: IA A148861) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IA G163179) |
| 363LF0000X Nurse Practitioner, Family (Licence: MO 2009015609) | |
| Enumeration Date | 2017-06-02 |
| Last Update Date | 2022-07-21 |