| NPI | 1962965996 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: TX AP140083) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TX AP140083) |
| 363LF0000X Nurse Practitioner, Family (Licence: MD AC002644) | |
| Enumeration Date | 2019-04-08 |
| Last Update Date | 2023-12-29 |