| NPI | 1780100917 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MT NUR-APRN-LIC-127120) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WY 53464) |
| Enumeration Date | 2017-08-18 |
| Last Update Date | 2024-01-11 |