| NPI | 1659850345 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: MA RN2368659) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: KS 78321) |
| 363LP0200X Nurse Practitioner, Pediatrics (Licence: MO 2018027810) | |
| Enumeration Date | 2018-08-13 |
| Last Update Date | 2022-10-25 |