| NPI | 1972887107 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL 9207634) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL 9207634) |
| Enumeration Date | 2011-10-06 |
| Last Update Date | 2018-03-21 |