| NPI | 1821098484 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3002053) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: KY 2053P) |
| 363L00000X Nurse Practitioner (Licence: IN 71001019A) | |
| Enumeration Date | 2005-07-26 |
| Last Update Date | 2012-10-12 |