| NPI | 1881033280 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: OH COA15504NP) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WV 78818) |
| Enumeration Date | 2013-06-19 |
| Last Update Date | 2014-03-25 |