| NPI | 1720695224 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: SD CP002047) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IA A160877) |
| 363LF0000X Nurse Practitioner Family (Licence: NE 113865) | |
| Enumeration Date | 2020-09-29 |
| Last Update Date | 2022-04-06 |