| NPI | 1982080719 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: TN 20243) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: VA 0024174236) |
| Enumeration Date | 2015-08-04 |
| Last Update Date | 2017-01-30 |