| NPI | 1154316073 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: TX 681173) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: FL ARNP9321278) |
| Enumeration Date | 2005-09-16 |
| Last Update Date | 2012-06-13 |