| NPI | 1477000578 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: OK 105205) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: OK 106205) |
| 363LP0200X Nurse Practitioner, Pediatrics (Licence: OK 106205) | |
| Enumeration Date | 2016-09-06 |
| Last Update Date | 2017-10-11 |