| NPI | 1104328046 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TX AP137208) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TX AP137208) |
| 363LF0000X Nurse Practitioner, Family (Licence: TX 793707) | |
| Enumeration Date | 2018-03-07 |
| Last Update Date | 2022-08-04 |