| NPI | 1790055648 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: IN 71003877A) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: OH APRN.CNP.13472) |
| Enumeration Date | 2012-01-10 |
| Last Update Date | 2022-07-07 |