| NPI | 1871967422 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: WY 36862.1476) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: CO RN.0204483) |
| 363LF0000X Nurse Practitioner, Family (Licence: CO APN.0992157-NP) | |
| Enumeration Date | 2015-11-19 |
| Last Update Date | 2019-01-17 |