| NPI | 1962979914 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: PA SP019810) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: PA RN592456) |
| Enumeration Date | 2018-10-29 |
| Last Update Date | 2021-01-27 |