| NPI | 1871594002 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: UT 8583872-4405) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: AZ AP2158) |
| Enumeration Date | 2005-08-10 |
| Last Update Date | 2013-09-04 |