| NPI | 1710403746 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ID 60637) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: ID CNP60637) |
| Enumeration Date | 2017-08-22 |
| Last Update Date | 2019-10-11 |