| NPI | 1962738187 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3008089) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: NC 5004526) |
| Enumeration Date | 2009-10-22 |
| Last Update Date | 2019-05-21 |