| NPI | 1982355525 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: UT 8351269-4405) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: UT 83512694405) |
| Enumeration Date | 2022-01-14 |
| Last Update Date | 2022-07-15 |