| NPI | 1972502474 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TX 0390828-22) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: TX 255200) |
| Enumeration Date | 2005-07-18 |
| Last Update Date | 2007-11-09 |