| NPI | 1700341161 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: SC 22750) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NC 5011558) |
| Enumeration Date | 2019-02-09 |
| Last Update Date | 2022-10-05 |