| NPI | 1194262022 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: UT 7765348-4405) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: UT 7765348-4408) |
| Enumeration Date | 2017-01-30 |
| Last Update Date | 2024-08-26 |