| NPI | 1962854968 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TN 21295) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TN APN21295) |
| 163W00000X Registered Nurse (Licence: TN RN123498) | |
| Enumeration Date | 2016-07-01 |
| Last Update Date | 2017-02-14 |