| NPI | 1205883576 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: UT 167758-1205) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: UT 204952-4405) |
| Enumeration Date | 2006-05-30 |
| Last Update Date | 2021-02-16 |