| NPI | 1972208726 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP2300X Nurse Practitioner, Primary Care (Licence: TX 1115467) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TX F03230487) |
| 208D00000X General Practice (Licence: TX F03230487) | |
| Enumeration Date | 2023-04-03 |
| Last Update Date | 2026-05-29 |