| NPI | 1811547532 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MS 903568) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MS TACK-9YD0RY) |
| Enumeration Date | 2019-09-14 |
| Last Update Date | 2019-10-07 |