| NPI | 1609429182 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: SD CP001626) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2019-07-23 |
| Last Update Date | 2022-09-19 |