| NPI | 1710255815 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 98500) |
| Additional Taxonomies | 208M00000X Hospitalist (Licence: GA 98500) |
| 367500000X Nurse Anesthetist, Certified Registered (Licence: KY 4023024) | |
| Enumeration Date | 2011-12-05 |
| Last Update Date | 2025-01-14 |