| NPI | 1700053832 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: VA 0024190280) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: VA 0126001068) |
| 363L00000X Nurse Practitioner (Licence: VA 00024190280) | |
| Enumeration Date | 2008-05-08 |
| Last Update Date | 2024-07-25 |