| NPI | 1417991423 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TX 648384) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TX AP110973) |
| Enumeration Date | 2006-06-16 |
| Last Update Date | 2020-09-14 |