| NPI | 1770952889 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP2300X Nurse Practitioner, Primary Care (Licence: FL 9375663) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TX AP142941) |
| Enumeration Date | 2015-09-18 |
| Last Update Date | 2020-07-16 |