| NPI | 1508864067 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NH 046201-23) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: MA 228830) |
| 363LP0200X Nurse Practitioner, Pediatrics (Licence: NH 046201-23) | |
| Enumeration Date | 2005-07-08 |
| Last Update Date | 2020-06-24 |