| NPI | 1760906010 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: OK 99997) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WI 8167-33) |
| 363L00000X Nurse Practitioner (Licence: MN 5628) | |
| 363LF0000X Nurse Practitioner, Family (Licence: OK 99997) | |
| Enumeration Date | 2017-07-28 |
| Last Update Date | 2023-11-20 |