| NPI | 1700952082 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: VA 0001143524) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: VA 0024143524) |
| 363LF0000X Nurse Practitioner, Family (Licence: VA 0024143524) | |
| Enumeration Date | 2006-11-28 |
| Last Update Date | 2007-09-11 |