| NPI | 1982999504 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: OK 209311) |
| Additional Taxonomies | 164W00000X Licensed Practical Nurse (Licence: OH PN.133673-M-IV) |
| Enumeration Date | 2011-06-11 |
| Last Update Date | 2022-07-20 |