| NPI | 1366111254 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: AZ 262345) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: AZ RN169147) |
| Enumeration Date | 2021-09-13 |
| Last Update Date | 2021-11-04 |