| NPI | 1255931655 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5013688) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: NC 5013688) |
| Enumeration Date | 2020-10-27 |
| Last Update Date | 2023-07-11 |