| NPI | 1659649606 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: GA RN176462) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: GA 2011008422) |
| Enumeration Date | 2011-12-06 |
| Last Update Date | 2011-12-06 |