| NPI | 1790392264 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TX 1015125) | 
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CA 95036938) | 
| Enumeration Date | 2020-09-28 | 
| Last Update Date | 2025-10-30 |