| NPI | 1710962519 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IA 119257) |
| Additional Taxonomies | 367500000X Nurse Anesthetist, Certified Registered (Licence: IA D119257) |
| Enumeration Date | 2005-12-14 |
| Last Update Date | 2015-09-25 |