| NPI | 1164151064 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: UT 10217335-4405) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: UT 10217335-3102) |
| Enumeration Date | 2022-06-07 |
| Last Update Date | 2022-06-21 |