| NPI | 1689667131 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NM CNP01097) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NM R45721) |
| Enumeration Date | 2005-08-30 |
| Last Update Date | 2013-12-23 |