| NPI | 1780045856 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: PA SP016198) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: WV 83837) |
| Enumeration Date | 2016-03-16 |
| Last Update Date | 2019-05-10 |