| NPI | 1679851059 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: TN 28855) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: TX AP136104) |
| 363LF0000X Nurse Practitioner Family (Licence: LA AP06627) | |
| Enumeration Date | 2011-08-02 |
| Last Update Date | 2021-05-12 |