| NPI | 1700506086 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TX 1048117) |
| Additional Taxonomies | 261QU0200X Clinic/Center, Urgent Care |
| Enumeration Date | 2022-08-29 |
| Last Update Date | 2023-05-04 |