| NPI | 1790309631 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TX 1067747) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WA AP61078054) |
| Enumeration Date | 2020-06-06 |
| Last Update Date | 2022-05-27 |