| NPI | 1053984567 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TX 1048099) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL 11023438) |
| Enumeration Date | 2021-07-21 |
| Last Update Date | 2023-04-24 |