| NPI | 1104934116 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NM r66418) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: TX 691712) |
| Enumeration Date | 2006-08-29 |
| Last Update Date | 2015-08-07 |