| NPI | 1235755521 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TX 1029905) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: VA 0024179531) |
| Enumeration Date | 2020-06-22 |
| Last Update Date | 2022-04-29 |