| NPI | 1619965639 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: TX 645712) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: CA 95008845) |
| Enumeration Date | 2005-10-13 |
| Last Update Date | 2022-07-21 |