| NPI | 1114595121 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TX 1043973) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TX 1049373) |
| Enumeration Date | 2021-06-15 |
| Last Update Date | 2025-03-24 |