| NPI | 1821143389 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TX 668237) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL RN9255221) |
| Enumeration Date | 2007-01-24 |
| Last Update Date | 2012-07-11 |