| NPI | 1669260584 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IA A185223) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: TX 1068345) |
| 163W00000X Registered Nurse (Licence: TX 1068345) | |
| Enumeration Date | 2025-04-29 |
| Last Update Date | 2025-07-22 |