| NPI | 1720677420 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TX 1020160) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: TX 10201299) |
| Enumeration Date | 2021-01-16 |
| Last Update Date | 2021-03-08 |