| NPI | 1124567607 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: VI AP11092) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: TX AP132841) |
| Enumeration Date | 2017-02-17 |
| Last Update Date | 2017-02-17 |