| NPI | 1821477589 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NC 5007813) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: SC 21148A) |
| Enumeration Date | 2015-05-27 |
| Last Update Date | 2019-02-12 |