| NPI | 1669789475 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5015034) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: OH COA.11706-NP) |
| Enumeration Date | 2010-09-01 |
| Last Update Date | 2023-12-20 |