| NPI | 1780016915 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5006315) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: NC 5006315) |
| Enumeration Date | 2013-07-30 |
| Last Update Date | 2015-04-15 |