| NPI | 1649240979 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KY 6167) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: IA A093798) |
| Enumeration Date | 2006-01-26 |
| Last Update Date | 2009-09-24 |