| NPI | 1750899142 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3013589) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IN 71011373A) |
| 363LF0000X Nurse Practitioner Family (Licence: FL 9330723) | |
| Enumeration Date | 2018-01-19 |
| Last Update Date | 2021-11-02 |