| NPI | 1912302886 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: LA 205105) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: MS 903836) |
| Enumeration Date | 2014-11-04 |
| Last Update Date | 2020-02-25 |