| NPI | 1811654205 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TX 1070207) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: TX 940276) |
| Enumeration Date | 2021-11-20 |
| Last Update Date | 2022-02-09 |