| NPI | 1134762594 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: UT 9100065-4405) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: UT 9100065-3102) |
| Enumeration Date | 2019-10-17 |
| Last Update Date | 2020-07-15 |