| NPI | 1467012120 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: VA 0024177706) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: NC 0024177706) |
| 208000000X Pediatrics (Licence: VA 0024177706) | |
| Enumeration Date | 2019-06-15 |
| Last Update Date | 2022-10-28 |