| NPI | 1720191901 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: TX 644331) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: TX 644331) |
| Enumeration Date | 2006-08-15 |
| Last Update Date | 2015-08-12 |