| NPI | 1861511560 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0200X Nurse Practitioner Pediatrics (Licence: CT 113855) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner Pediatrics (Licence: MA 230954) |
| 363LP0200X Nurse Practitioner Pediatrics (Licence: VT 101.0058221) | |
| Enumeration Date | 2007-03-27 |
| Last Update Date | 2015-01-21 |