| NPI | 1164909149 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: FL APRN9347812) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL ARNP9347812) |
| Enumeration Date | 2018-07-23 |
| Last Update Date | 2019-10-28 |