| NPI | 1770045536 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NE 112769) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IA A157340) |
| Enumeration Date | 2019-04-02 |
| Last Update Date | 2020-08-03 |