| NPI | 1790759991 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: OR 201150022NP) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: IL 209005250) |
| Enumeration Date | 2006-02-14 |
| Last Update Date | 2012-09-04 |