| NPI | 1124779616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: TX 1074012) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: FL 11015267) |
| Enumeration Date | 2022-01-16 |
| Last Update Date | 2022-09-09 |