| NPI | 1720539125 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KS 5378465022) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WY 37815.1561) |
| Enumeration Date | 2016-10-20 |
| Last Update Date | 2019-10-14 |