| NPI | 1891821583 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: LA RN078162) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: LA APO3664) |
| Enumeration Date | 2007-02-26 |
| Last Update Date | 2008-01-02 |