| NPI | 1881014769 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2013010838) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KS 53-75791-062) |
| Enumeration Date | 2014-04-18 |
| Last Update Date | 2015-10-28 |