| NPI | 1942206941 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: CO 108964) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NE 60261) |
| Enumeration Date | 2005-06-23 |
| Last Update Date | 2007-07-09 |