| NPI | 1679081251 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5011753) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: GA RN244538) |
| 363LF0000X Nurse Practitioner, Family (Licence: GA RN244538) | |
| Enumeration Date | 2018-01-17 |
| Last Update Date | 2020-01-31 |