| NPI | 1780298091 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL f08200696) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0024180154) |
| Enumeration Date | 2020-09-03 |
| Last Update Date | 2020-12-02 |