NPI | 1679161129 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: SC 27166) |
Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WV 108116) |
Enumeration Date | 2021-01-08 |
Last Update Date | 2024-04-12 |