| NPI | 1912417577 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: AZ F10170411) |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care |
| Enumeration Date | 2017-10-09 |
| Last Update Date | 2018-05-05 |