| NPI | 1356073407 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5016440) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner Pediatrics (Licence: NC 5016440) |
| Enumeration Date | 2022-06-28 |
| Last Update Date | 2022-09-30 |