| NPI | 1649551797 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3007032) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: KY 3007032) |
| Enumeration Date | 2011-09-02 |
| Last Update Date | 2014-12-23 |