| NPI | 1477263614 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: SC 26848) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: LA 228120) |
| 363LP0200X Nurse Practitioner, Pediatrics (Licence: LA 228120) | |
| Enumeration Date | 2022-11-29 |
| Last Update Date | 2023-01-05 |