| NPI | 1750817557 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 57849) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: UT 9589355-3102) |
| Enumeration Date | 2017-05-11 |
| Last Update Date | 2020-09-01 |