| NPI | 1700080652 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TX 674942) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: TX 674942) |
| Enumeration Date | 2007-06-13 |
| Last Update Date | 2022-08-01 |