| NPI | 1760596175 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: UT 320175-4405) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: UT 320175-4405) |
| Enumeration Date | 2006-08-19 |
| Last Update Date | 2009-05-22 |