| NPI | 1982107736 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ID 72095) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TX AP136272) |
| Enumeration Date | 2018-03-16 |
| Last Update Date | 2025-03-14 |