| NPI | 1790258341 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: VA 0024177184) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: TN 193244) |
| Enumeration Date | 2019-01-07 |
| Last Update Date | 2019-04-12 |