| NPI | 1881169662 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NC 5011221) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NC WIGG-4VFGTP) |
| Enumeration Date | 2018-10-09 |
| Last Update Date | 2018-11-30 |