| NPI | 1780768259 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 2488P) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KY 2488P) |
| Enumeration Date | 2006-10-24 |
| Last Update Date | 2020-12-09 |