| NPI | 1376716399 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: UT 374258-4405) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: UT 374258-8900) |
| Enumeration Date | 2008-04-10 |
| Last Update Date | 2010-11-24 |