| NPI | 1306830070 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: IA C090162) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: IA 090162) |
| Enumeration Date | 2005-09-08 |
| Last Update Date | 2007-10-16 |