| NPI | 1639778822 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: SD CP001861) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: SD CP001861) |
| Enumeration Date | 2020-10-20 |
| Last Update Date | 2021-09-29 |