| NPI | 1689139040 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: AL F01191470) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: AL 1-138196) |
| Enumeration Date | 2019-02-08 |
| Last Update Date | 2021-01-14 |