| NPI | 1255539821 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TX AP132602) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CA 17346) |
| 363LF0000X Nurse Practitioner, Family (Licence: IA A150308) | |
| Enumeration Date | 2007-07-05 |
| Last Update Date | 2018-05-10 |