| NPI | 1922077940 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3012624) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NC 201201) |
| 363L00000X Nurse Practitioner (Licence: NC 201201) | |
| Enumeration Date | 2006-03-14 |
| Last Update Date | 2019-03-20 |