| NPI | 1376729012 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TX 705558) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TX 70558) |
| Enumeration Date | 2008-01-11 |
| Last Update Date | 2012-07-30 |