| NPI | 1942329180 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LA2200X Nurse Practitioner Adult Health (Licence: TX AP126769) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: TX SA00005) |
| Enumeration Date | 2007-03-28 |
| Last Update Date | 2014-10-26 |