| NPI | 1992768261 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KY 38929) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KY 38929) |
| 363LF0000X Nurse Practitioner Family (Licence: KY 38929) | |
| Enumeration Date | 2006-04-08 |
| Last Update Date | 2021-09-30 |