| NPI | 1033105473 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: TX 774561) |
| Additional Taxonomies | 111NS0005X Chiropractor Sports Physician (Licence: TX 6736) |
| Enumeration Date | 2005-09-21 |
| Last Update Date | 2022-09-16 |