| NPI | 1770906695 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: OK R0093117) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: OK 93117) |
| 363LF0000X Nurse Practitioner, Family (Licence: OK 93117) | |
| Enumeration Date | 2014-01-28 |
| Last Update Date | 2020-04-28 |