| NPI | 1104649771 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TX 1120453) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: TX 1120453) |
| Enumeration Date | 2024-11-04 |
| Last Update Date | 2026-06-22 |