| NPI | 1912247263 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: FL 9435037) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: TN 17348) |
| 363LF0000X Nurse Practitioner Family (Licence: MD AC001862) | |
| Enumeration Date | 2013-02-25 |
| Last Update Date | 2017-05-10 |