| NPI | 1154383305 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner Pediatrics (Licence: UT 195992-4405) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: UT 195992-8900) |
| Enumeration Date | 2006-04-04 |
| Last Update Date | 2011-01-19 |