| NPI | 1770520348 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: MO 114307) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MO RN114307) |
| Enumeration Date | 2006-06-01 |
| Last Update Date | 2022-09-14 |