| NPI | 1912354739 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5008581) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NC 260336) |
| Enumeration Date | 2016-05-23 |
| Last Update Date | 2021-05-27 |