| NPI | 1376731885 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TX 775309) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TX 775309) |
| 363LF0000X Nurse Practitioner, Family (Licence: CA NP 16316) | |
| Enumeration Date | 2007-10-09 |
| Last Update Date | 2014-05-05 |