| NPI | 1083287296 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: FL 11013205) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: FL APRN11013205) |
| Enumeration Date | 2021-07-23 |
| Last Update Date | 2022-08-24 |