| NPI | 1659026029 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0200X Nurse Practitioner Pediatrics (Licence: GA RN274857) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: GA RN274857) |
| Enumeration Date | 2022-02-15 |
| Last Update Date | 2023-10-10 |