| NPI | 1669727087 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5005854) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: SC 217133) |
| Enumeration Date | 2012-07-23 |
| Last Update Date | 2021-07-22 |