Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LG0600X | Nurse Practitioner - Gerontology | 072247-23 | NH |
NPI | 1073114674 |
---|---|
Provider Name | Alex Mutuku |
First Address | Bedford, NH 03110-0115 |
Second Address | Bedford, NH 03110-4941 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/11/2020 |
Last Update Date | 02/11/2020 |