| NPI | 1912443847 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: ID 54931) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL 11012549) |
| Enumeration Date | 2017-01-17 |
| Last Update Date | 2022-03-28 |