| NPI | 1639887896 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: UT 13012445-4405) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: PA sp025667) |
| Enumeration Date | 2022-11-07 |
| Last Update Date | 2022-11-07 |