| NPI | 1851744411 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5008708) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: VA 24180437) |
| 363LF0000X Nurse Practitioner Family (Licence: NC 5008708) | |
| Enumeration Date | 2016-07-19 |
| Last Update Date | 2020-11-30 |