| NPI | 1730569492 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WA AP60588606) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: ID N36661) |
| Enumeration Date | 2015-06-08 |
| Last Update Date | 2021-04-27 |