| NPI | 1386227304 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TX 989250) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2021-04-29 |
| Last Update Date | 2024-10-11 |