| NPI | 1184239063 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL 11009024) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: TX 1036264) |
| 363LF0000X Nurse Practitioner, Family (Licence: TX 1036264) | |
| Enumeration Date | 2020-09-09 |
| Last Update Date | 2024-01-19 |