| NPI | 1154024396 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TX 1103054) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX 1103054) |
| Enumeration Date | 2023-03-27 |
| Last Update Date | 2023-04-10 |