| NPI | 1942601497 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TX AP130247) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: GA RN209150) |
| Enumeration Date | 2014-09-15 |
| Last Update Date | 2018-06-01 |