| NPI | 1710459623 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: LA 203824) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: LA RN122676) |
| Enumeration Date | 2018-12-18 |
| Last Update Date | 2019-04-02 |