| NPI | 1073192076 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WA AP61177403) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: TX AP143896) |
| 363L00000X Nurse Practitioner (Licence: WA N361178562) | |
| Enumeration Date | 2021-04-06 |
| Last Update Date | 2021-09-29 |