| NPI | 1962757963 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: OH APRN.CNP.13343) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: WV 62758) |
| Enumeration Date | 2012-07-17 |
| Last Update Date | 2021-07-14 |