| NPI | 1205183688 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: MO 2021021932) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: MO 2021021932) |
| 363LP0200X Nurse Practitioner, Pediatrics (Licence: NV APRN001810) | |
| 163W00000X Registered Nurse (Licence: WI 179993-30) | |
| Enumeration Date | 2012-08-05 |
| Last Update Date | 2022-07-22 |