| NPI | 1831167105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: MO 2000167996) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KS 53-74934-022) |
| 163W00000X Registered Nurse (Licence: MO 2000167996) | |
| Enumeration Date | 2006-03-10 |
| Last Update Date | 2014-11-19 |