| NPI | 1154449973 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MT NUR-APRN-LIC-265788) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NM APRNCNP82174) |
| 363LF0000X Nurse Practitioner, Family (Licence: GA GAA-NP002756) | |
| 363LF0000X Nurse Practitioner, Family (Licence: SD CP003673) | |
| 163W00000X Registered Nurse (Licence: TX 748767) | |
| 363AS0400X Physician Assistant, Surgical (Licence: TX SA00366) | |
| 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11035520) | |
| 363LF0000X Nurse Practitioner, Family (Licence: MT 265788) | |
| Enumeration Date | 2007-03-27 |
| Last Update Date | 2025-09-22 |