| NPI | 1780678201 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TN RN110566) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TN 7410) |
| Enumeration Date | 2005-09-12 |
| Last Update Date | 2018-02-15 |