| NPI | 1528099231 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: UT 1996264405) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: UT 8900CS) |
| Enumeration Date | 2006-07-05 |
| Last Update Date | 2007-07-08 |