| NPI | 1730404658 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 250145) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: FL ARNP9248128) |
| Enumeration Date | 2010-04-03 |
| Last Update Date | 2012-09-20 |