| NPI | 1770891210 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NC 5010071) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: SC 4335) |
| Enumeration Date | 2010-09-17 |
| Last Update Date | 2019-10-29 |