| NPI | 1780202077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TX 230389) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: TN 230389) |
| Enumeration Date | 2020-07-13 |
| Last Update Date | 2022-03-30 |