| NPI | 1891338059 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: OK 134792) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: KS 53-79076-102) |
| Enumeration Date | 2019-10-21 |
| Last Update Date | 2019-12-27 |