| NPI | 1578803078 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: VA 0024128887) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: VA 0001128887) |
| Enumeration Date | 2013-02-20 |
| Last Update Date | 2023-03-07 |