| NPI | 1376196097 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA NP95011755) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TX AP141488) |
| Enumeration Date | 2019-07-22 |
| Last Update Date | 2023-01-18 |