| NPI | 1184934622 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: KY 3006586) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: KY 1095067) |
| 363LF0000X Nurse Practitioner, Family (Licence: KY 6586P) | |
| Enumeration Date | 2010-10-18 |
| Last Update Date | 2011-05-31 |