| NPI | 1861148926 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner Pediatrics (Licence: MS 906479) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MS 900730) |
| Enumeration Date | 2022-02-28 |
| Last Update Date | 2025-06-03 |