| NPI | 1912203183 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: OR 201504135NP-PP) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: OR 201140139RN) |
| Enumeration Date | 2011-02-04 |
| Last Update Date | 2022-01-04 |