| NPI | 1942586755 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IA A111437) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: IA A-111437) |
| Enumeration Date | 2011-10-25 |
| Last Update Date | 2013-08-07 |