| NPI | 1679611511 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: LA 229619) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TX AP139494) |
| Enumeration Date | 2007-02-02 |
| Last Update Date | 2024-08-14 |