| NPI | 1639646086 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: FL APRN11002964) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: TX AP138258) |
| 363LF0000X Nurse Practitioner Family (Licence: MN 6336) | |
| Enumeration Date | 2018-10-24 |
| Last Update Date | 2019-08-14 |