| NPI | 1568958122 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: NC 5010720) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NC 5010720) |
| Enumeration Date | 2018-07-07 |
| Last Update Date | 2024-07-15 |