| NPI | 1801164389 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: GA 210808) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NC RN250110) |
| Enumeration Date | 2011-12-12 |
| Last Update Date | 2020-05-11 |