| NPI | 1780839175 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL 9298719) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NY F335699) |
| Enumeration Date | 2008-11-26 |
| Last Update Date | 2012-09-23 |