| NPI | 1790104909 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN2758262) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: FL ARNP2758262) |
| 363LF0000X Nurse Practitioner, Family (Licence: CA 95013836) | |
| 363LF0000X Nurse Practitioner, Family (Licence: NY F345222-01) | |
| Enumeration Date | 2014-04-15 |
| Last Update Date | 2020-11-02 |