| NPI | 1710489018 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: GA RN225712) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: GA 225712) |
| Enumeration Date | 2018-03-02 |
| Last Update Date | 2020-11-07 |