| NPI | 1679622054 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: PA TP005647B) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: PA TP005647B) |
| Enumeration Date | 2007-01-09 |
| Last Update Date | 2020-08-11 |