| NPI | 1972599447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: VA 0024102283) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: VA 0024102283) |
| Enumeration Date | 2005-09-21 |
| Last Update Date | 2022-06-13 |