| NPI | 1255304176 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: NM CNP02896) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: OK R0034727) |
| 363LP0200X Nurse Practitioner, Pediatrics (Licence: AZ AP4644) | |
| Enumeration Date | 2006-02-10 |
| Last Update Date | 2016-05-27 |