| NPI | 1770643231 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MD AC000290) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: VA 0001151805) |
| 363L00000X Nurse Practitioner (Licence: DC RN61669) | |
| Enumeration Date | 2006-12-12 |
| Last Update Date | 2012-01-03 |