| NPI | 1760848204 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TN 20898) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: TN 198628) |
| 363LF0000X Nurse Practitioner, Family (Licence: VA 0024173331) | |
| Enumeration Date | 2016-01-14 |
| Last Update Date | 2020-05-19 |