| NPI | 1154325991 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: UT 271062-4405) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: UT 271062-4405) |
| Enumeration Date | 2005-06-09 |
| Last Update Date | 2020-12-17 |