| NPI | 1962647610 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: LA 05610 APRN) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: LA 100696 RN) |
| Enumeration Date | 2008-12-10 |
| Last Update Date | 2011-11-16 |