| NPI | 1588063754 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: NC 5007064) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: NC 18227) |
| Enumeration Date | 2014-08-13 |
| Last Update Date | 2021-05-10 |