| NPI | 1609158930 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner Pediatrics (Licence: IA C158874) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner Pediatrics (Licence: AZ TAP4187) |
| Enumeration Date | 2011-09-13 |
| Last Update Date | 2021-02-22 |