| NPI | 1376178772 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: AZ 241654) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: AZ RN183515) |
| Enumeration Date | 2020-03-05 |
| Last Update Date | 2020-12-10 |