| NPI | 1174503635 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 201912) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: NC 201912) |
| 363LF0000X Nurse Practitioner, Family (Licence: NC 201912) | |
| Enumeration Date | 2006-01-20 |
| Last Update Date | 2024-04-09 |