| NPI | 1205037322 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TX AP133741) |
| Additional Taxonomies | 111NR0400X (Licence: TX DC9074) |
| Enumeration Date | 2007-05-29 |
| Last Update Date | 2017-04-12 |