| NPI | 1700139946 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TX AP122729) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: LA 229814) |
| Enumeration Date | 2012-10-25 |
| Last Update Date | 2023-04-20 |