| NPI | 1174089718 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: AZ 289574) | 
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NM 71452) | 
| 363LF0000X Nurse Practitioner, Family (Licence: TX AP140311) | |
| Enumeration Date | 2019-02-19 | 
| Last Update Date | 2025-08-05 |