| NPI | 1912780479 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: TX 1131801) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: TX 1131801) |
| Enumeration Date | 2023-08-17 |
| Last Update Date | 2023-08-17 |