| NPI | 1871935825 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3008113) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IN 71008934A) |
| 363LF0000X Nurse Practitioner, Family (Licence: KY 3008113) | |
| Enumeration Date | 2013-07-18 |
| Last Update Date | 2019-04-23 |