| NPI | 1912042839 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: VA 0024166662) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: VA 0024166662) |
| Enumeration Date | 2007-02-20 |
| Last Update Date | 2013-07-09 |