| NPI | 1790454106 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TX 1077489) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NY 348314) |
| Enumeration Date | 2021-09-09 |
| Last Update Date | 2023-02-03 |