| NPI | 1740759182 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: LA 212148) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: TX Ap138179) |
| Enumeration Date | 2018-11-15 |
| Last Update Date | 2021-06-14 |