| NPI | 1861031759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: WI 258532-30) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MN 6841) |
| Enumeration Date | 2019-12-26 |
| Last Update Date | 2021-03-05 |