| NPI | 1467017715 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: CT 17665) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: CT 17665) |
| Enumeration Date | 2019-05-02 |
| Last Update Date | 2026-07-17 |