| NPI | 1477124253 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: WA AP70023739) | 
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TX 1046658) | 
| 363LF0000X Nurse Practitioner, Family (Licence: AZ 328363) | |
| Enumeration Date | 2021-07-02 | 
| Last Update Date | 2025-10-07 |