| NPI | 1902563356 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: NC 5021631) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: AZ 300922) |
| Enumeration Date | 2021-11-19 |
| Last Update Date | 2026-07-31 |