| NPI | 1992253959 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: FL 9318352) |
| Additional Taxonomies | 363LP2300X Nurse Practitioner Primary Care (Licence: FL 9318352) |
| Enumeration Date | 2016-09-19 |
| Last Update Date | 2016-09-19 |