| NPI | 1669846812 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TX 1076140) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: SC 20122) |
| 363L00000X Nurse Practitioner (Licence: GA RN276968) | |
| Enumeration Date | 2015-11-25 |
| Last Update Date | 2023-12-17 |