| NPI | 1881792455 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WA AP60076323) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner Pediatrics (Licence: OR 088006164N2 PNP-PP) |
| 363LP0200X Nurse Practitioner Pediatrics (Licence: AZ RN091542 182) | |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2018-03-17 |