| NPI | 1417504093 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: LA 207540) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TX AP142698) |
| Enumeration Date | 2019-08-20 |
| Last Update Date | 2019-08-20 |