| NPI | 1780148577 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NC 5015405) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: FL 9503033) |
| 363LF0000X Nurse Practitioner, Family (Licence: FL 11015082) | |
| Enumeration Date | 2019-01-25 |
| Last Update Date | 2021-12-08 |