| NPI | 1831228147 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: DE LJ0000311) | 
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: PA SP008398) | 
| 363LP0200X Nurse Practitioner, Pediatrics (Licence: CT 002543) | |
| Enumeration Date | 2007-03-04 | 
| Last Update Date | 2017-02-22 |