| NPI | 1356856132 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: GA RN274800) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TX AP135884) |
| Enumeration Date | 2017-12-03 |
| Last Update Date | 2019-10-15 |