| NPI | 1912436478 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: UT 10391008-4405) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: ID 55473) |
| Enumeration Date | 2017-06-08 |
| Last Update Date | 2022-02-15 |