| NPI | 1790187565 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NM CNP-03401) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner Pediatrics (Licence: NM CNP-03401) |
| 163W00000X Registered Nurse (Licence: CO RN.0185546) | |
| 363LP0200X Nurse Practitioner Pediatrics (Licence: CO APN.0991376-NP) | |
| Enumeration Date | 2014-09-23 |
| Last Update Date | 2025-09-06 |