| NPI | 1770568727 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 113431) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: KY 3009332) |
| Enumeration Date | 2005-12-13 |
| Last Update Date | 2016-03-16 |