| NPI | 1104864628 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: TX AP114175) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: TX 618904) |
| Enumeration Date | 2006-06-04 |
| Last Update Date | 2017-10-18 |