| NPI | 1972850964 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MO 2012027796) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MO 127915) |
| Enumeration Date | 2012-08-08 |
| Last Update Date | 2016-02-10 |