| NPI | 1083259147 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LG0600X Nurse Practitioner, Gerontology (Licence: TX ap143936) |
| Additional Taxonomies | 363LG0600X Nurse Practitioner, Gerontology (Licence: AZ 323041) |
| Enumeration Date | 2019-11-13 |
| Last Update Date | 2025-08-29 |