| NPI | 1841691003 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: ID 55392) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: OR 201703051) |
| Enumeration Date | 2014-09-08 |
| Last Update Date | 2023-01-19 |