| NPI | 1710985023 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: DC RN50094) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MD R080264) |
| 363L00000X Nurse Practitioner (Licence: LA 56210-2320) | |
| Enumeration Date | 2005-07-11 |
| Last Update Date | 2007-07-08 |