| NPI | 1750855300 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WA AP61344041) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX AP138415) |
| 363L00000X Nurse Practitioner (Licence: LA 208374) | |
| Enumeration Date | 2019-01-16 |
| Last Update Date | 2022-09-20 |