| NPI | 1669494084 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP2300X Nurse Practitioner, Primary Care (Licence: MO 2018007737) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: AL 1-079966) |
| 363LF0000X Nurse Practitioner, Family (Licence: OH RN343732) | |
| 363LP2300X Nurse Practitioner, Primary Care (Licence: OH NP-10573) | |
| Enumeration Date | 2006-07-24 |
| Last Update Date | 2018-03-07 |