| NPI | 1851642219 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: SC 18063) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: VA 0024170350) |
| Enumeration Date | 2012-09-26 |
| Last Update Date | 2019-06-10 |