| NPI | 1649869017 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TX AP1020167) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: TX AP1020167) |
| Enumeration Date | 2021-01-11 |
| Last Update Date | 2021-01-11 |