| NPI | 1790236453 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: FL 9448517) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: MI 4704283426) |
| Enumeration Date | 2016-10-18 |
| Last Update Date | 2018-08-11 |