| NPI | 1972683274 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 285099) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: TX 535643) |
| Enumeration Date | 2006-10-17 |
| Last Update Date | 2016-11-16 |