| NPI | 1902150626 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TX 717283) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: TX AP122661) |
| Enumeration Date | 2012-11-02 |
| Last Update Date | 2020-07-16 |