| NPI | 1972708493 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KS 45612) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KS 13-69014-121) |
| Enumeration Date | 2007-06-15 |
| Last Update Date | 2007-07-08 |