| NPI | 1851316897 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: SD CP000104) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SD 0242) |
| Enumeration Date | 2006-07-12 |
| Last Update Date | 2012-01-31 |