| NPI | 1790035947 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP2300X Nurse Practitioner Primary Care (Licence: TX AP108836) |
| Additional Taxonomies | 163WG0000X Registered Nurse General Practice (Licence: TX 551280) |
| 163WG0600X Registered Nurse Gerontology (Licence: TX 551280) | |
| Enumeration Date | 2012-09-14 |
| Last Update Date | 2015-09-03 |