| NPI | 1700039005 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TX 684424) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: TX 684424) |
| Enumeration Date | 2008-10-30 |
| Last Update Date | 2011-03-30 |