| NPI | 1750867248 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IA A130813) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IA F07181382) |
| Enumeration Date | 2018-07-17 |
| Last Update Date | 2021-09-13 |