| NPI | 1356995708 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: FL APRN11002786) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: TX 1016187) |
| Enumeration Date | 2019-07-24 |
| Last Update Date | 2024-08-13 |