| NPI | 1962458919 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: VA 0024166579) |
| Additional Taxonomies | 207P00000X Emergency Medicine (Licence: TN 11581) |
| Enumeration Date | 2006-05-25 |
| Last Update Date | 2010-11-19 |