| NPI | 1780138123 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: PA SP016303) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: PA SP016303) |
| Enumeration Date | 2016-08-14 |
| Last Update Date | 2024-05-17 |