| NPI | 1700242112 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TX AP129867) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: NM CNP-02890) |
| 363LP0200X Nurse Practitioner, Pediatrics (Licence: TX AP129867) | |
| Enumeration Date | 2016-01-14 |
| Last Update Date | 2023-12-07 |