| NPI | 1902369671 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2021035759) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: KS 53-78679-061) |
| 363LF0000X Nurse Practitioner, Family (Licence: MO 2021035759) | |
| Enumeration Date | 2019-04-10 |
| Last Update Date | 2021-11-08 |