| NPI | 1952741340 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: GA RN290948) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CO 0990776) |
| 363LF0000X Nurse Practitioner, Family (Licence: TX AP139989) | |
| Enumeration Date | 2013-06-28 |
| Last Update Date | 2020-06-09 |