| NPI | 1568129997 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: MA 10002642) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: NY 383353) |
| Enumeration Date | 2021-11-19 |
| Last Update Date | 2024-11-21 |