| NPI | 1700913910 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: LA A10443) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: LA PA.A10443) |
| Enumeration Date | 2007-02-27 |
| Last Update Date | 2009-05-28 |