| NPI | 1790206159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: AZ AP10442) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: AZ AP10442) |
| Enumeration Date | 2017-07-06 |
| Last Update Date | 2021-04-28 |