| NPI | 1790654804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX 1216097) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: TX 1216097) |
| Enumeration Date | 2025-11-05 |
| Last Update Date | 2025-12-10 |