| NPI | 1679580260 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MO 2012022796) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: KS 44323) |
| Enumeration Date | 2006-08-03 |
| Last Update Date | 2012-07-26 |