| NPI | 1679113559 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX 913371) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: TX 913371) |
| Enumeration Date | 2020-01-08 |
| Last Update Date | 2025-02-10 |