| NPI | 1770920621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TN 17660) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: VA 0024170905) |
| Enumeration Date | 2013-06-03 |
| Last Update Date | 2015-06-25 |