| NPI | 1174810204 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: NY F382212-1) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: NY 382212) |
| Enumeration Date | 2011-07-10 |
| Last Update Date | 2015-07-16 |