| NPI | 1780921320 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KS 53-75903-041) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MO 2013009798) |
| Enumeration Date | 2013-01-15 |
| Last Update Date | 2020-12-22 |