| NPI | 1982690863 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: ID NP570A) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: ID NP570A) |
| Enumeration Date | 2005-09-26 |
| Last Update Date | 2011-09-22 |