| NPI | 1710240916 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3013514) |
| Additional Taxonomies | 363LA2100X Nurse Practitioner, Acute Care (Licence: MS R870265) |
| 363LF0000X Nurse Practitioner, Family (Licence: MS R870265) | |
| Enumeration Date | 2012-06-21 |
| Last Update Date | 2019-08-14 |