| NPI | 1790055077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: OR 201250002NP) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WA AP60260387) |
| Enumeration Date | 2012-01-04 |
| Last Update Date | 2021-06-22 |