| NPI | 1871357426 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TX 1167694) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: UT 9521708-4405) |
| Enumeration Date | 2024-02-13 |
| Last Update Date | 2024-09-22 |