| NPI | 1720097512 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CO 0004452) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: CO 103080) |
| Enumeration Date | 2006-08-08 |
| Last Update Date | 2021-08-11 |