| NPI | 1316329220 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: UT 7942683-4405) |
| Additional Taxonomies | 261QX0100X Clinic/Center Occupational Medicine |
| 261QP2300X Clinic/Center Primary Care | |
| 261QU0200X Clinic/Center Urgent Care | |
| Enumeration Date | 2015-06-26 |
| Last Update Date | 2020-07-08 |