| NPI | 1851351332 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: VA 0110840824) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: VA 0110840824) |
| Enumeration Date | 2006-03-27 |
| Last Update Date | 2008-05-20 |