| NPI | 1174162192 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP2300X Nurse Practitioner, Primary Care (Licence: UT 5834623-4405) |
| Additional Taxonomies | 2083P0500X Preventive Medicine, Preventive Medicine/Occupational Environmental Medicine (Licence: UT 5834623-4405) |
| 363LA2200X Nurse Practitioner, Adult Health (Licence: UT 5834623-4405) | |
| 363LF0000X Nurse Practitioner, Family (Licence: UT 5834623-4405) | |
| Enumeration Date | 2019-12-23 |
| Last Update Date | 2021-04-22 |