| NPI | 1578021473 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: FL APRN11014592) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: FL 2289024) |
| Enumeration Date | 2019-03-10 |
| Last Update Date | 2021-10-19 |