| NPI | 1407555360 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TX 1112778) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: TX 962690) |
| Enumeration Date | 2023-03-01 |
| Last Update Date | 2023-03-13 |