| NPI | 1861765414 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KY 3007282) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: OH COA 13141-NP) |
| Enumeration Date | 2012-02-13 |
| Last Update Date | 2021-03-10 |