| NPI | 1164034013 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: TN 27837) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: OH 0035641) |
| 363L00000X Nurse Practitioner (Licence: TN 27837) | |
| Enumeration Date | 2020-08-21 |
| Last Update Date | 2024-09-06 |