| NPI | 1700879459 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ID NP-704A) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: ID NP-704) |
| Enumeration Date | 2005-08-29 |
| Last Update Date | 2012-11-15 |