| NPI | 1689654394 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: DC 30297876) |
| Additional Taxonomies | 163WP2201X Registered Nurse, Ambulatory Care (Licence: VA 0001169726) |
| Enumeration Date | 2006-01-19 |
| Last Update Date | 2011-10-17 |