| NPI | 1801101613 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2011034116) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: KS 141455) |
| Enumeration Date | 2010-08-17 |
| Last Update Date | 2011-12-23 |