| NPI | 1720523418 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IA A165967) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NC 5009250) |
| 363L00000X Nurse Practitioner (Licence: ID 71001) | |
| 363LF0000X Nurse Practitioner, Family (Licence: NC 5009250) | |
| Enumeration Date | 2017-01-04 |
| Last Update Date | 2022-12-27 |