| NPI | 1912040072 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: SC 25108) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: SC 236991) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: SC 663) | |
| Enumeration Date | 2007-02-15 |
| Last Update Date | 2021-06-24 |