| NPI | 1770113011 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: TX AP145567) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX AP145567) |
| Enumeration Date | 2020-01-24 |
| Last Update Date | 2021-08-19 |