| NPI | 1730547688 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: OR 201807336NP-PP) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MA RN2302360) |
| 363L00000X Nurse Practitioner (Licence: MI 4704323816) | |
| Enumeration Date | 2016-02-07 |
| Last Update Date | 2020-05-29 |