| NPI | 1932192820 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NM CNP00390) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NM R22744) |
| Enumeration Date | 2005-08-25 |
| Last Update Date | 2011-08-01 |