| NPI | 1912156407 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TX AP129918) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: IL 041368825) |
| Enumeration Date | 2008-09-09 |
| Last Update Date | 2022-09-02 |