| NPI | 1770183303 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: VA 0024181317) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: VA 0001267153) |
| Enumeration Date | 2020-11-01 |
| Last Update Date | 2021-10-14 |