| NPI | 1942855663 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MA RN2262596) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: GA RN276218) |
| Enumeration Date | 2019-08-08 |
| Last Update Date | 2021-03-05 |