| NPI | 1679127880 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NM 57036) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NM 57036) |
| Enumeration Date | 2019-07-25 |
| Last Update Date | 2021-01-05 |